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A Piece of My Mind |

Interpreters or Teachers?

Abraham M. Nussbaum, MD, MTS1
[+] Author Affiliations
1Denver Health, Behavioral Health, Denver, Colorado; and University of Chicago Program on Medicine and Religion, Chicago, Illinois
JAMA. 2013;310(3):265-266. doi:10.1001/jama.2013.8321.
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Like many psychiatrists, I eagerly awaited the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), which corrects problems identified in earlier versions of our diagnostic manual while incorporating recent advances. The DSM-5 task force included leaders in psychiatry who worked for the better part of a decade to review evidence and revise diagnoses and diagnostic criteria. The task force made potential changes in diagnostic criteria available online, sought public comment, and revised the diagnoses again through expert review.1 Afterward, they conducted field trials at academic medical centers to assess reliability. Despite all of this learned effort, the interrater reliability of one of the most common mental disorders, major depressive disorder, remains discouragingly low, with a κ of 0.28 in both adults and children indicating only “questionable agreement” between two mental health clinicians evaluating the same person for depression.2 Because most diagnoses of major depressive disorder occur in community settings, where the criteria are presumably applied less rigorously, what are we saying when we diagnose a person with major depressive disorder? More broadly, what does this say about what goes on when we physicians directly examine a patient?

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